ED Admit to Inpatient Rm
EPIC: ED: TRANSFER NOTE
ATT: @ATTPROV@
PCP: @PCP@
@NAME@ @AGE@(@BDAY@)
@DEPTNME@
@RRHLOS@
MRN: @MRN@
Current attending in ED: @ATTPHY@
SYNOPSIS
@NAME@ is a @AGE@ @SEX@ ***
@NOTESUMMARIES(1&0&0)@
{SNP Linked Labs:23727}
Admitted for
@PROBLEM@
@PROB@
NURSING HANDOFF
Plan: Pending workup/admit . All questions answered to the patient’s satisfaction. All personal belongings were with the patient including all electronics, clothing, and valuables. Pt sent w/medical paperwork. Charge RN aware.
DISPO: NAD, VSS
BELONGINGS: clothing and cell phone
REPORT GIVEN TO: RN
TRANSPORTATION: gurney via tech
DESTINATION: tbd
ASSESSMENT
NOTES ENDORSED TO RECEIVING NURSE:
•
NEURO:
- Aoxo4
RESPIRATORY:
- No SOB
CARDIAC:
- NSR
GI:
- swallows pills ok
{SNP Linked Labs:23727}
@DIETORD@
GU:
- uses urinal
SKIN:
- normal
FAMILY:
- at bedside
VITALS
VITALS
24 Hour Min / Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@
LAST VS:
@VS@
LABS
@LABBRIEF(NA,CL,BUN,K,CO2,CREATININE,GLUCOSE)@
@LABBRIEF(WBC,HGB,HCT,PLATELETS)@
@LABBRIEF(PT,INR,APTT)@
@LABBRIEF(CA,MG,PHOS)@
@LABBRIEF(ALB,LACTICACID,LACTWBVENPC,TROPONINHS,HGBA1C)@
@LABRCNT24(POCGLUCOSE:*)@
DRIPS
ICU DRIPS & CONTINUOUS IV’s
LINES:
PIVs
•
IMAGING
@IMAGERESULTS48H@
NURSING PLAN
Maintenance Tasks
-add/maintain PIVs, check need for CVC/Foley
-monitor electrolytes
-strict I/o when ordered
-neuro checks periodically
-monitor HGB; check s/s bleeding
-ensure airway trach patency
-elevate arms, if app
-d/w attending pt status
-turned pt q2h
-fall risk observed
-wound care/prevention as necessary
-skin checks q shift w/RN 4 eyes verification
Report given to oncoming RN, , at transfer, who then assumed all care.
Howie Realubit, BSN, RN, CCRN
Electronic Signature
@TD@ @NOW@